Mohsen Saidinejad, MD, MBA, FAAP
Children’s National Health System
With the passage of meaningful use act of 2009, requiring a phased implementation of electronic health record (EHR) system, more and more healthcare organizations have rushed to beat the technology compliance clock and to be eligible for incentives and reimbursements. As a result of this electronic transformation, all patient-encounter data is now potentially more transparent, accurate and up to date.1 More importantly, data is more accessible, shareable, and coordinated.2 On the flipside, reliance of digital data can paralyze the entire system during system downtimes, data breaches, or data loss. In addition to this, back-up systems and servers that are sometimes thousands of miles away can potentially put sensitive personal patient information at risk. EHRs are also expensive and are challenging to successfully implement without growing pains. Electronic documentation also can be more tedious and time-consuming. In this article, we examine the impact of EHRs specifically on ED providers.
A large number of EHRs are currently available in the market. The products offered by these companies range from very simple tablet-based patient intake documentation to extremely complex network of dynamic and multiple-source data management system for thousands of patient encounters. Literature supports the fact that EHRs improve patient care quality and potentially decrease errors. 3 Other studies show that EHRs do not adversely affect any of the 8 measures of ED operational efficiency.4 These include metrics such as door-to-provider time, length of stay, discharge, and admissions.
In the era of performance-based provider compensation, however, EHRs also potentially hinder ED providers who are under increasing pressure to generate more revenue value units (RVUs) and to have high patient satisfaction scores. Electronic documentation takes longer than the traditional paper-based documentation, it contains time-stamped events, which put performance pressure on the ED providers, and it can stress the system even during transient “down-times”. The learning curve is also more substantial compared to traditional paper charting.
While having and EHR does not necessarily improve quality, meaningful use of EHRs can transform patient care. For ED providers, especially in busy EDs, EHRs improve delivery of patient care in some of the following ways:
- Medication dosage calculator and two-level verification significantly reduce prescribing errors.
- Clinical disease specific treatment pathways can be launched from the EHR directly and immediately, decreasing door to treatment times.
- Electronic prescribing (e-prescriptions) allow home medications orders to be transmitted directly to the pharmacy, saving patient time and stress.
- Standardized pre-completed patient encounter notes and texts allows providers to complete a chart in a much more time-efficient manner.
- Electronic tracking board is critical in patient flow management and provides real-time waiting times, patient location, and patient acuity in the ED.
- Information can not be misinterpreted due to issues such as poor penmanship or error in decimal placement
- Trainee documentation can be routed for editing and correction is more efficient and simple with an EHR system.
EHRs can allow providers to access a complete full of information from laboratory tests, radiographic images, consultations notes, as inpatient and outpatient encounters simultaneously and better understand the patient’s needs. More importantly, an EHR system allows information to be recorded in one place and be viewed instantly at a remote location. This can optimize care coordination and saves healthcare providers valuable time. Finally, ED providers can potentially have access to the patient records, including other encounters on demand and from any place with an Internet connection.
Time spent documenting is one of the common issues facing ED providers. Time pressure, and limited ability to do complete and concise documentation affect ED providers more than any others. Personal customization can save time and decrease charting burden for ED providers. Some of the helpful customizations include:
- Creating pre-completed note templates
- Creating a list of custom discharge instructions
- Copy and pasting recurring information
- Creating custom trainee supervisory text
- Creation of common medications folder
- Develop a two person verification of sensitive orders (e.g. narcotics)
- Creation of various clinical pathways with pre-selection of common steps (e.g. asthma pathway is clicked for patient with weight 15kg, and weight-based doses of medication treatments are auto-selected, and upon signing, all orders automatically populate)
Overall, EHRs actually do not increase time burden on ED providers if meaningfully and effectively used. They eliminate paper waste, improve documentation, improve awareness, and protect the providers against medication and some many other documentation errors. The most important fact is that EHRs should not be treated as one size fit all. Selecting the correct EHR is critically important as is selecting of the various functionalities. EHRs are not the only approach to decreasing healthcare costs and improving patient care efficiency, but rather, are part of an infrastructure that is required to optimize quality care and process efficiency.
*Note: This is the first and introductory article in the series for the topic of “Improving ED throughput, efficiency, and patient experience”.